The full range of mental health issues found in the general student population can also be found in the life of student-athletes. And the mental health of a college student is compounded by any number of factors of student life.

College students are adapting to a new environment, are responsible for managing their time, exploring their new-found freedom, attempting to meet the demands of college coursework, and making choices regarding personal behavior. Participation in athletics does not provide the student-athlete with any immunity from those stressors. In fact, as a result of being a visible person on campus, it may even serve to heighten it.

Frantic Schedules

Participation in collegiate athletics imposes additional demands and stressors on student-athletes. They include the physical demands of training and competition, as well as the nearly year-round time commitment to their sport. Student-athletes often miss holidays, semester and summer breaks, classes and family events due to training and competition.

The typical day in the life of a student-athlete is fully scheduled, with class, meetings with instructors, group projects, workouts or practice (sometimes starting at 6 a.m.), study or tutor time, injury treatments, meetings with coaches and teams and community service. Add in travel days during both traditional and non-traditional seasons, and student-athletes are fully engaged in the demands of school and their sport for months at a time, with little personal time.

Additionally, many student-athletes define themselves by their identity as an athlete. They may struggle in their performance, have difficulty interacting with their coach or teammates or lose their passion for practicing and playing the sport. Any time-loss injury, chronic injury, or career-ending injury or medical condition may create or worsen the stress felt by the student-athlete.

As a certified athletic trainer with more than 30 years experience at the collegiate level, I and many of my colleagues nationwide have helped identify and refer many student-athletes for mental health evaluation and care.

Recent news reports of suicides and mental health incidents involving athletes serve as reminders that institutions and their staffs should enhance their awareness of potential student-athlete mental health issues, and develop plans on meeting this demand.

Growing Awareness

Many recent studies have highlighted the mental health issues faced by college students and student-athletes. Following are only a few of the many studies that demonstrate this growing concern.

A study out of San Diego State University found that five times as many high school and college students are dealing with anxiety and other mental health issues than youth of the same age who were studied during the Great Depression (Associated Press, Jan. 11, 2010).

Another study indicated that 45 percent of college-age students say they have been so depressed that it was difficult to function, and 10 percent have seriously considered suicide (NCAA Double-A-Zone, online blog of the NCAA, July 15, 2009).

Young adults aged 18 to 25 with serious psychological distress were less likely than other adults with serious psychological distress to have received mental health services (SAMHSA's 2007 National Survey on Drug Use and Health).

According to a University of Pittsburgh survey by Robert Gallagher, more than 90 percent of university counseling directors reported seeing students with significant psychological problems. Issues include clinical depression, eating disorders, suicidal thoughts and cutting (Detroit Free Press online edition, Jan. 4, 2010).

Athletic trainers and therapists are in a position to observe and interact with student-athletes on a daily basis. As health care professionals, athletic trainers have received clearly designed education and training, and are certified to practice in their defined scope of practice.

However, unless educated, trained and credentialed as a mental health care professional, health care providers are not licensed to treat a mental health illness, and should leave mental health evaluation and treatment to those professionals who are trained and credentialed to do so.

People react to stress in varying degrees. Not all student-athletes who have difficulty managing stress have a mental health issue. A difficult moment, put into context, such as cursing after a loss (or at teammates and opponents), throwing equipment or fighting during practice or game, are understandable and are seen on a daily basis.

I've personally witnessed countless numbers of student-athletes who are otherwise level-headed and mature act out in frustration over something in a game or practice. This is where experience with young adults and specifically understanding the competitive nature of student-athletes helps discern appropriate reactions to situational stress.

Recently I performed an informal survey of athletic department personnel and mental health professionals-counselors, clinical psychologists and psychiatrists. I asked them, "What's the most important thing someone should know or be aware of regarding a potential mental illness in a student-athlete?"

The athletic department personnel responded with, "Knowing what number to call for help." What I learned through this survey has reshaped my approach to this issue, and is something I want to share with my colleagues.

Mental health care professionals felt the most important skill to possess was identifying a potential mental health issue through observing "the behaviors to monitor." People are defined by their behavior, and any deviation from their established pattern may be a sign of a potential issue.

Addressing the Issue

Approaching anyone with a concern over their mental well-being is an uncomfortable experience. It's important to have your facts straight before arranging a private meeting with the student-athlete.

It's equally important to let the student understand that others care about them as a person, and that being referred for an evaluation for a potential mental health issue is no different than being evaluated for an injury or an illness.

To start this uncomfortable conversation, consider using some of the following questions:

• "How are things going for you?"

• "Tell me what's going on."

• "Your behavior (mention the incident or incidents) has me concerned. Can you tell me what's going on, or is there something I need to know to understand what happened?"

• "Tell me how those cuts (or other wounds) got there."

• "Do you feel like harming yourself or others?"

• "I want to help you, but this type of issue is beyond my scope as a (coach, administrator, athletic trainer); I know where to send you for help with this issue."

• "Talk with me about your diet."

Developing a relationship with the director of counseling is important. Those charged with referring the student-athlete, usually the athletic trainer, should keep in touch with the director and counseling staff in an ongoing manner, even when their services are not required. Assist the student-athlete in making the initial appointment for an evaluation.

There are student-athletes who may refuse counseling for various reasons, namely the long-held belief that counseling carries a stigma. Unless the behavior raises concern for imminent health or safety reasons, or a code of conduct violation has not taken place, the student-athlete cannot be compelled to report for a mental health evaluation. Encourage the student-athlete to consider an evaluation by a counselor to help him deal more effectively with personal stress or issues.

If the student-athlete reports suicidal feelings or comments, or that he feels like harming not only themselves but others, call a member of the counseling services and/or public safety/police immediately, and either remain where you are or accompany the student-athlete to a facility where the staff may instruct you to go. Do not leave the athlete alone. Be sure to leave your cell phone number with the staff or police in order to keep in constant contact.

Student-athletes are encouraged to inform their coach and parents or guardians of the situation. However, if the student-athlete wishes to have his condition remain private, that wish should be respected.

An exception to granting the wish for privacy lies in the event of a criminal activity, harm that has occurred to the student-athlete, or a potential suicide or harm to others. Consultation with the office of student affairs and/or legal counsel should be required prior to releasing information against the wishes of the student-athlete.

Navigating the uncharted waters of student-athlete mental health issues is challenging. Collaborating with mental health professionals and institutional and athletic department administration, along with raising the awareness of athletic department personnel to behaviors to monitor, are all positive steps in proactively preparing for potential student-athlete mental health issues that are already present on our nation's campuses.

Timothy Neal is a certified athletic trainer and assistant director of athletics for sports medicine at Syracuse (NY) University.

This article was produced in cooperation with the National Athletic Trainers' Association (NATA), the professional membership association for certified athletic trainers and those who support the athletic training profession. For more information visit www.nata.org

Causes for Concern: Behaviors To Watch For

• Changes in eating and sleeping habits;

• Drug and alcohol abuse;

• Feeling guilty or worthless;

• Withdrawing from social contact;

• Decreased interest in activities that have been enjoyable;

• Talking about death, dying or "going away;"

• Loss of emotion or extreme changes of emotion (mania);

• Problems concentrating, focusing or remembering, or
inability to make decisions;

• Frequent complaints of fatigue, illness or injury;

• Unexplained wounds or deliberate self-harm;

• Becoming more irritable or anxious;

• Significant personal events that increase the risk for
depression, suicide, homicide (sudden death of a loved one,
or a sudden end to the athlete's playing career due to injury).

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